title: Management of mustard gas-induced limbal stem cell deficiency and keratitis.
abstract: OBJECTIVE
  To report the clinical findings and compare outcomes of different surgical techniques evolved over time in a large series of patients with delayed-onset mustard gas keratitis (MGK).
  
  
  METHODS
  Retrospective, comparative, interventional case series.
  
  
  METHODS
  Ninety Iranian male survivors (175 eyes) of Iraqi chemical warfare with chronic or delayed-onset MGK.
  
  
  METHODS
  The symptoms and clinical findings of patients are presented, and medical and surgical interventions to address dry eye, limbal ischemia and limbal stem cell deficiency (LSCD), and corneal involvements are explained. The results of limbal stem cell transplantation techniques (living-related conjunctival-limbal allograft [lrCLAL] versus keratolimbal allograft [KLAL]) as well as corneal transplantation techniques (penetrating keratoplasty [PK] versus lamellar keratoplasty [LK]) are compared in terms of clinical outcomes and graft survival rates.
  
  
  METHODS
  Ocular findings and appropriate surgical approach for LSCD and corneal involvements.
  
  
  RESULTS
  A total of 175 eyes of 90 cases (all male) between 34 and 68 years of age were followed up for 101±30.3 months (range, 36-198 months). The most common ocular involvements were chronic blepharitis and dry eye. Conjunctival vascular abnormalities and limbal ischemia were observed in 27.4% and 29.7% of eyes, respectively. Limbal stem cell deficiency necessitating stem cell transplantation developed in 41.1% of eyes. The most common corneal sign was central and peripheral anterior stromal opacity (58.9%), followed by corneal stromal thinning (36.0%) and neovascularization (27.4%). Living-related conjunctival-limbal allograft was performed in 32 eyes, and KLAL was performed in 40 eyes. The rejection-free graft survival rate was 39.1% in the lrCLAL group and 80.7% in the KLAL group at month 40, with a mean length of 24.9 and 68.8 months, respectively (P = 0.02). Thirty eyes underwent PK and 51 underwent LK. Corneal graft failure was observed in 9 PK eyes and in 6 LK eyes. The rejection-free graft survival rate was 39.0% in the PK group and 90.3% in the LK group at month 28, with a mean length of 29.6 and 85.0 months, respectively (P<0.001).
  
  
  CONCLUSIONS
  Chemical warfare victims who initially have mild symptoms ultimately may experience significant ocular involvements requiring surgical intervention. Limbal and corneal abnormalities can be managed best by KLAL and LK, respectively.
authors.affiliation: Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. ma_javadi@yahoo.com
authors.forename: Mohammad Ali
authors.initials: MA
authors.lastname: Javadi
authors.forename: Mohammad Reza
authors.initials: MR
authors.lastname: Jafarinasab
authors.forename: Sepehr
authors.initials: S
authors.lastname: Feizi
authors.forename: Farid
authors.initials: F
authors.lastname: Karimian
authors.forename: Kambiz
authors.initials: K
authors.lastname: Negahban
mesh_terms: D000328:Adult; D000368:Aged; D002619:Chemical Warfare Agents / Q000494:pharmacology*; D016039:Corneal Transplantation / Q000379:methods*; D006801:Humans; D007634:Keratitis / Q000139:chemically induced / Q000601:surgery*; D016850:Limbus Corneae / Q000187:drug effects / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009151:Mustard Gas / Q000494:pharmacology*; D011182:Postoperative Care; D012189:Retrospective Studies; D033581:Stem Cell Transplantation; D013234:Stem Cells / Q000187:drug effects* / Q000473:pathology; D013997:Time Factors
chemical_list: D002619:Chemical Warfare Agents; D009151:Mustard Gas